Racially diverse individuals are underrepresented in the field of athletic training. Previous research identified multiple factors that may contribute to diversity concerns including a lack of access to higher education, underrepresentation, financial instability, lack of programming, and mentoring for minoritized students through matriculation in health care education programs.
To identify current recruitment and retention strategies aimed at racially minoritized students in athletic training programs.
Consensual qualitative research.
A total of 14 professional athletic training program directors (age = 47 ± 7 years; years credentialed = 25 ± 7 years; years in role = 13 ± 7 years).
This qualitative study used consensual qualitative research methodology with the incorporation of multianalyst triangulation and member checking to establish trustworthiness. The interview protocol consisted of questions regarding current recruitment and retention strategies used by directors of professional master's programs.
Four domains emerged from the study: (1) benefits of diversity, (2) marketing, (3) individualized support, and (4) enrollment management strategies. Participants expressed that diversity could lead to a more inclusive and positive learning environment and could improve patient care through establishing race concordance on the program Web site, social media, and other print materials. Program directors demonstrated a lack of awareness relative to available professional resources and the difference between creating equal versus equitable resources. Participants demonstrated variability in their awareness of enrollment management strategies, specific to admissions resources and professional resources.
Program directors appreciate the benefits of racial diversity and are actively engaged in marketing strategies to recruit minoritized students. They are also working to retain minoritized students but may be providing equal, rather than equitable, resources. Professional athletic training programs must continue to develop and promote effective strategies for admissions, support matriculation, and increase identifiable and equitable resources to better serve minoritized students.
Program directors demonstrated a lack of awareness regarding the difference between equitable and equal resources when it comes to diversity and inclusion.
Program directors indicated that the cost of education, availability of financial assistance, and location of their respective institutions were the main barriers to recruiting racially minoritized students.
Program directors noted that media and marketing materials should be inclusive, yet they were conscientious about displaying a false image or asking their racially minoritized student(s) to be in all their photos.
If given the choice, racially minoritized patients are more likely to choose providers who look like them.1 The decision to choose a provider who shares the same race, ethnicity, and/or gender is a complex process that is influenced by many factors.2–5 Patients who are treated in race-concordant relationships often report higher patient outcomes, higher satisfaction, and increased engagement on behalf of their physicians.4 Current literature highlights the need for patients to have access to providers who share their same racial or ethnic background.4 A lack of access to a preferable physician negatively influences health care outcomes and has an effect on the overall issue of health care disparities in minoritized communities.4 One way to address the issue of access to diverse providers is to increase the diversity of the health care workforce, thus ensuring minoritized individuals the opportunity to choose a provider who looks like them.
Several studies have been conducted throughout various health care settings regarding diversity and inclusivity.6–10 These studies found that there are numerous reasons that may contribute to the lack of diversity in the health care workforce, including the lack of racially diverse people's access to higher education, institutionalized racism, financial instability, and an absence of mentoring.6–10 A study that focused on black women in athletic training found that a lack of financial support and the presence of sexism and racism within the institution, classroom, and clinical sites were all factors that could negatively affect a minoritized student's ability to matriculate through athletic training education.9 Research on diversity in nursing education programs found that minoritized students graduate at higher rates when they are provided with mentorship programs, tutoring, goal setting, financial support, and structured accountability.7,10 However, a study that focuses on recruitment and retention strategies aimed at minoritized students in athletic training education has yet to be completed.
White people account for over 80% of athletic trainer (AT) members of the National Athletic Trainers' Association, whereas only 3% are Black and 4% are Hispanic.11 Currently, no study has addressed and explored the specific factors that contribute to the lack of racial diversity in the field of athletic training as a result of the lack of diversity in educational programs. This study aimed to address the lack of diversity in athletic training by considering the recruitment and retention within professional-level education. The purpose of this study was to explore the recruitment and retention strategies aimed at racially minoritized students for professional athletic training programs delivered at the professional master's level.
This study used the consensual qualitative research (CQR) design to examine the lived experiences of professional athletic training program directors relative to their current recruitment and retention strategies aimed at racially minoritized students in athletic training programs at the professional master's level.12 In addition to the qualitative interview, demographic data were collected via a Web-based survey to capture objective data regarding race of the program director, racial diversity of the students enrolled in various programs, and the racial diversity of the respective institutions.
Participants and Setting
This study was approved by the Indiana State University Institutional Review Board. We used criterion sampling to select participants. They were required to be a program director for a Commission on Accreditation of Athletic Training Education (CAATE)–accredited professional athletic training program delivered at the professional master's level (n = 181). Exclusion criteria included not being a director of a CAATE-accredited program or not having a cohort of students who completed at least 1 year of the master's program. Email addresses for CAATE-accredited professional athletic training programs delivered at the professional master's level were gathered via a publicly available database. An initial email was sent on June 10, 2019, and a follow-up email was sent 1 week later. The recruitment survey was closed 2 weeks after initial emails were sent. A total of 40 program directors completed the demographic survey, with 16 individuals agreeing to participate in the interview. Of those, 14 met the inclusion criteria for the study. The participants included 10 women (72%) and 4 men (28%) and were typically midcareer (age = 47 ± 7 years, mean = 13 years of experience as a program director). Table 1 provides a full demographic list with corresponding pseudonyms assigned to each participant.
Qualitative interview questions were developed on the basis of existing literature related to recruitment and retention of racially diverse students throughout multiple medical disciplines as well as literature related to race relations and culturally competent health care (Table 2).6,7,10 The interview protocol was reviewed by a panel of 3 content experts. Content experts were ATs with published research conducted in racial and ethnic studies. The content experts were asked to provide feedback about the content, flow, and relevance of the interview question set as it related to the project aims. The qualitative interview script was edited on the basis of the provided feedback from the panel of content experts. The primary investigator (PI) conducted a practice interview to ensure the clarity and flow of the questions with 1 individual who met the inclusion criteria.
Upon ethics approval, e-mail addresses for the program directors were entered into a Web-based survey-distribution software (Qualtrics, Provo, UT). Participants received an e-mail containing the survey link and were instructed to click on the link. Upon clicking the survey link, the participant was presented with the digital informed consent followed by basic demographic questions and asked to provide their preferred contact information for an individual follow-up interview. Interviews were scheduled and conducted 1-on-1 over the teleconferencing software (version 3.6; Zoom, San Jose, CA), using the phone/audio feature only, and were audio recorded to ensure transcription accuracy. The PI conducted all interviews, which lasted from 20 to 30 minutes.
Data Analysis and Trustworthiness
Audio files were then transcribed verbatim and deidentified. Participants were then sent their deidentified interview transcripts to ensure accuracy before coding in a process called member checking.12 The data analysis team consisted of the PI (K.A.W.) and two other researchers (L.E.E., Z.K.W.). One member of the research team was a novice in CQR methodology, whereas the other 2 members of the team and the auditor were considered experienced or expert CQR researchers. Each member of the team independently read 3 randomly selected transcripts and met to develop a domain list reflective of the data.12 The team met to compare their initial domain list and develop the consensus codebook of the domains and conceptualize the core ideas.12 The initial codebook was then applied to 2 of the original transcripts and 3 new transcripts.12 This phase of the process was incorporated to ensure that the initial codebook was truly reflective of the domains that emerged from the transcripts.12
During the next phase, the consensus codebook was applied to the remaining transcripts individually, such that each of the 3 members of the data analysis team coded 4 or 5 transcripts and met after coding to reach a consensus.12 Finally, a cross-analysis of multiple participant interviews was constructed to ensure that core ideas were accurately placed in the domains and categories.12 After data analysis was completed, the interview script, consensus codebook, cross-analyses, and coded transcripts were shared with the auditor (J.R.E.N.).12 Triangulation of the data was ensured and trustworthiness was established by the use of multiple researchers, participant member checking, and auditing.12
The final stage of analysis consisted of frequency counting, which allowed the team to determine the frequency of each category across the whole sample.12 Frequency counting involved analyzing each coded transcript for each category. A category was considered general if it appeared in all 14 cases, typical if it appeared in 7 to 13 of the cases, and variant if it appeared in 3 to 6 cases.
Four domains emerged from the data: (1) benefits of diversity, (2) marketing, (3) individualized support, and (4) enrollment management strategies. Table 3 details the frequency for the coded data per category.
Benefits of Diversity
Participants described benefits to having diversity, specifically benefits to patient care and benefits within the learning environments. Participants often described that having diversity provided a range of positive outcomes.
Diversity was described, both about current literature and participants in this study, as an avenue to increase positive patient outcomes through establishing race-concordant relationships.4 Participants explained that ATs are providing a public service and that a lack of racial diversity provides a disservice to the profession and the patients that they serve. Patients deserve the opportunity to be treated by people who look like them or have similar cultural backgrounds to them. Participants also expressed awareness that the current racial demographic of ATs does not reflect the racial demographic of the population being served.
Regarding learning environments, racial diversity was reported to provide a unique and wide range of perspectives to the classroom and the clinic. Participants expressed that having a diverse student population not only improves patient outcomes and experience but also increases the student's ability to effectively collaborate with individuals who may not have similar personal or professional experiences. Racial diversity in the learning environment aids in creating a well-rounded and culturally aware individual. Supporting quotes from each of the categories are available in Table 4.
Participants explained marketing strategies that included inclusive media, insular marketing, and people within this domain.
Participants described the importance of creating and disseminating marketing materials that include verbiage and images that were respectful to and inclusive of racially minoritized students. Participants also expressed a desire to create marketing materials that were an honest reflection of the diversity of their programs without engaging in exploitation and misrepresentation.
Participants also stated that they often used program alumni and preceptors to help market their programs via word of mouth. Faculty diversity and advocacy was also mentioned as a marketing strategy used by participants. One participant mentioned the possibility of engaging with undergraduate student athletes as a recruiting strategy.
Participants also expressed that the geographical location of their institution either aided or hindered their efforts to recruit a diverse student population. Relying on location for marketing purposes is referred to as insular marketing. For participants whose institution was in a diverse community, their athletic training cohorts were often self-reported to be more diverse. Participants whose community lacked diversity and relied on insular marketing strategies self-reported a decrease in student diversity. Supporting quotes from each of the categories are available in Table 5.
Participants indicated that their programs provided individual support for students that was focused on acknowledging the student's identity, providing community, and supporting the student academically.
Recognizing the Student's Identity
Recognizing the student's identity encompasses the program director's ability to acknowledge and sequentially seek out support for a student on the basis of the individual's specific needs as a racially minoritized student. Participants who recognized the student's identity expressed the importance of minoritized students connecting with other minoritized students, faculty, and staff on campus and seeing representation.
Participants who were aware of available community support programs expressed intentionally connecting racially minoritized students to appropriate community resources including the Black Student Union, Hispanic Student Union, and culture-specific hair salons. Participants also mentioned the need to directly connect students with these resources.
Academic support included both cost and programming components. The cost component was made up of scholarships specifically created to help fund education for minoritized students. This was not exclusive to scholarships for tuition but also included book waivers and meal plans. Also mentioned was the overall cost of tuition at each university and the comparison between graduate and undergraduate program costs. Participants mentioned the need for racially minoritized students to work while in school to offset the tuition costs. Although working while being a student is not exclusive to racially minoritized students, it was noted as being more common among this demographic.
The academic programming component included mentoring, tutoring, and competency-based grading systems. The purpose of these academic programming considerations was to be more accommodating to minoritized students. Finally, participants expressed the availability of tutoring on an institutional and programmatic level as available support strategies. However, tutoring programs were mentioned as being offered to all students and not specifically designed for racially minoritized students. Many participants expressed that they know tutoring is available through the university but few mentioned supportive active engagements in tutoring. Supporting quotes from each of the categories are available in Table 6.
Enrollment Management Strategies
The enrollment management strategies domain yielded 3 categories that were divided into subcategories of awareness and lack of awareness. The categories within this domain included aware/unaware of admissions strategies, aware/unaware of equity, and aware/unaware of professional resources.
Admissions Strategies: Aware/Unaware
Awareness of admissions strategies aimed at racially minoritized students was expressed through active recruitment at historically black colleges and universities (HBCUs) and awareness of available funding for diversity recruitment. Participants also acknowledged outside factors that contribute to minoritized students' grade point average (GPA) such as working, taking care of a family member, or contributing to their own family's household income. One participant mentioned removing the Graduate Record Examination requirement for admissions. Participants who expressed a lack of awareness regarding admissions strategies expressed a lack of systems designed to target racially minoritized students and a lack of awareness on where and how to recruit minorities.
Awareness and lack of awareness regarding equity versus equality was another topic that emerged in this study. Lack of awareness of equity was noted through the “color-blind” approach, which is the ideology that all students should be treated the same regardless of their race. This color-blind approach negates the specific needs of racially minoritized students and delegitimizes the importance of an individualized approach to recruitment and retention. Awareness of equity was expressed through the creation of minority-mentoring programs and providing necessary accommodations for personal and professional experiences outside of the classroom.
Professional Resources: Aware/Unaware
Participants explained their awareness of professional resources through identifying available programs or initiatives that could assist in their recruitment or retention efforts, outside of those provided by their institution. The most common resource identified was the National Athletic Trainers' Association Ethnic Diversity Advisory Committee (EDAC). However, participants were grossly unaware of other professional resources from the CAATE or other organizations. Supporting quotes from each of the categories are available in Table 7.
Benefits of Diversity
Findings of this study suggest that program directors for professional athletic training programs appreciate the benefits of racial diversity. Many program directors acknowledged the need for race-concordant relationships in athletic training as a health care profession, which aligned with medical literature.2–5 Many participants in this study mentioned the negative outcomes that stemmed from a lack of diversity including decreased patient outcomes, perpetuation of the cycle of racially minoritized individuals' lack of trust in the health care system, lack of exposure to different opinions and life experiences, and the expunging of the opportunity to develop ATs who are culturally competent. These findings align with current literature, which indicates that a lack of diversity in health care education programs may lead to poor outcomes for students and patients, health care disparities, and culturally incompetent care.6,7,10 Diversity in education leads to an increase in diversity of the health care workforce and enhances academic experiences for all students.13
Participants mentioned that a diverse learning environment could lead to an increase in patient outcomes, aid in the development of culturally aware individuals, and increase a student's ability to collaborate with others. However, strategies on how to effectively create an inclusive learning environment were not discussed by participants. Published research focusing on racial diversity in athletic training may be lacking, but there is literature on this topic in other health care education curricula.7,10,14,15
Other health care professions have found success in creating a diverse classroom environment by implementing the following strategies: encouraging peer-to-peer relationship building, students receiving faculty validation, social integration, and acknowledgment of academic progression.13,14 Peer-to-peer relationship building can be facilitated through creating opportunities for students to engage with their peers both in and out of the classroom environment. This allows students to feel accepted and understood by their peers and facilitates true social integration.13,14 Faculty validation and acknowledgment of academic progression are necessary for minoritized students to feel valued, seen, and heard. This acknowledgment must come from faculty, peers, and support groups.13–15
Faculty engaged in development and implementation of curricula for master's-level athletic training programs should focus on personal development in cultural competency.13 Research indicates that ATs are culturally aware but lack actual implementation of culturally competent behaviors.16 This lack of demonstration of culturally competent behaviors may cause a lack of exposure to culturally competent preceptors and faculty. Faculty focus on the development of culturally competent behaviors will allow them to act as role models for students and encourage social integration, validation, and authentic relationship building with racially minoritized students.13–15 Dialogue about race, privilege, structural inequality, and discrimination must be addressed and encouraged in the classroom; avoidance and redirection are not effective solutions.17 Lack of faculty preparedness and willingness to be introspective, metacognitive, and authentic in their approach to these topics is not an excuse.17 Faculty should be prepared with the appropriate skill set to facilitate classroom dialogue, develop curriculum, and enact initiatives aimed at inclusivity.13,17,18
Participants expressed general knowledge of the need for diverse marketing. Participants presented interesting perspectives on how to accomplish this task. One participant specifically discussed a desire to create diverse marketing materials without making the 1 racially minoritized student feel targeted specifically because of race. Actively recruiting minoritized students and requesting their participation in the development of marketing materials to create the illusion of diversity is false advertisement.18 Engaging in this strategy can be seen as exploitation and misrepresentation.18 The goal of inclusive marketing should be to accurately represent the racial makeup of a specific program or entity.19
When creating marketing materials, it is important to have a strategic plan in place. There are 6 common steps to creating inclusive marketing (Table 8).20 Marketing materials should allow for representation while providing a realistic view of the actual racial diversity that exists.18 Given that many programs may have only 1 or 2 racially minoritized students, it is important to allow them the opportunity to participate in marketing while being honest about the racial makeup of the program.
Our participants often maximized relationships with current students, alumni, and preceptors to market their program. However, social media as a marketing strategy was not discussed. Current literature indicates that a large majority of students allow social media to influence their decision-making when searching for colleges to attend.21 Specifically, African American and Latinx populations are heavily influenced by social media.21 It is important for programs in higher education to highlight their programs, engage in “call to action” posts such as asking students to apply, and solicit content contributions from end users to increase their social media presence.22 Social media is another avenue where current and previous students can engage by reposting advertisements, creating short videos on their experiences, and creating content from their own viewpoints.22 Social media usage is an important resource when recruiting students.
Participants mentioned relying on geographic location as a hindrance for effectively recruiting minoritized individuals. Successful marketing and recruitment strategies that overcome insular restrictions collaborate with programs and institutions that are outside of their geographic location. In the medical community, partnerships with HBCUs as well as public school systems are common.23–25 Academic enrichment programs can also serve to assist in recruitment within undergraduate and high school programs. In one particular example, a nursing program created initiatives that aimed to create connection and increase racially minoritized students' exposure to health care.24 These programs can extend the reach of the program and incorporate inclusive marketing through collaborations with minoritized persons with potential interest in athletic training. The programs can also engage current students and alumni to offer learning opportunities as well as opportunities for volunteerism, mentorship, and professional engagement.
Recognizing the Student's Identity
Individualized support emerged as a domain and addressed the need for minoritized students to feel integrated and supported on multiple levels. This support may include tuition assistance, tutoring, mentorship, engagement in community programs, and building a positive campus climate.13 Colleges and universities should recognize a student's identity and create an environment that is welcoming and supportive. The literature indicates that predominantly white institutions that have successfully created inclusive campus climates have implemented awareness workshops, peer-to-peer development and interaction, on-campus social support, and diversity in curriculum and course structure.13
Participants mentioned the need for students to be engaged in community groups on campus and the need for awareness of resources outside the campus community. However, what was not mentioned by participants is the need for initiatives that address inclusion of minoritized students beyond the capacity of the individual program. True reform must include campuswide and state legislation.13 These initiatives should be aimed at creating funding, incorporating social justice, and creating programs specifically for minoritized individuals.13,18
The literature in nursing education highlights the effectiveness of mentorship programs to assist minoritized students.10,15,24,25 One participant in this study discussed how they initiated and implemented a minority mentorship program. This participant became aware of the fact that the attrition rate of minoritized students was high. Therefore, this participant sought out grant funding from the EDAC to establish the mentoring program, implemented it, and has seen improvements in the matriculation of racially minoritized students. This mentorship program should be highlighted as a great example of quality improvement and the creation of equitable academic support. All students are not the same and should be treated as individuals.
Enrollment Management Strategies
Admissions Strategies: Aware/Unaware
Program directors expressed that they are actively pursuing innovative ideas aimed at addressing admissions strategies. Participants mentioned removing the Graduate Record Examination and being aware of financial resources as potential avenues to making admissions strategies more inclusive. However, current literature indicates that recruitment efforts in education are not producing equity.18 Creating equitable resources and programming requires addressing, challenging, and changing systemic issues in higher education.18 Minoritized students must be given more than access to higher education. They must be allotted the resources necessary to succeed.18
An important aspect of this domain is addressing the discrepancies between creating equal and equitable resources.26 Equity requires the recognition and distribution of accommodations and assistance on the basis of the individual needs of the racially minoritized student population, whereas equality assumes that all students are the same and require the same resources.26 This color-blind ideology is fundamentally flawed and must be addressed to provide proper resources to racially minoritized communities.
Equity can be established through the creation of programs aimed specifically at racially minoritized students. Current literature in other health care professions supports the use of systematic programs designed to address the recruitment and retention of racially diverse students.25 Successful programs include initiatives aimed at financial assistance, academic and career counseling, tutoring, development of a comprehensive plan for retention and recruitment, mentoring, and appointment of specific staff or faculty who act as liaisons.23–26 Faculty should be keenly aware of developing recruitment and retention strategies that are built on foundational principles of minoritized individuals' learning styles.13 Faculty should also focus on the development of strategies that are based on diverse individuals' ideologies of learning and achievement.13 Finally, racially minoritized students must be encouraged through academic progression. Research shows that validation and affirmation of academic and clinical success must come from the faculty for racially minoritized individuals to feel connected to their programs.14 For racially diverse programming to be successful, students must feel welcomed, valued, integrated, accepted, and seen for the entirety of who they are as people.
Professional Resources: Aware/Unaware
Regarding availability of professional resources, participants were grossly unaware of where and how to access resources. The most mentioned resource was the EDAC within the NATA. Participants mentioned this resource, but many were unaware of the actual resources provided by this committee. The EDAC offers diversity-enhancement grants, iLead diversity grants, diversity statistics and reports, a mentorship panel, scholarships, and the Bill Chisolm Professional Service Award.27 The CAATE publishes a yearly analytic report that includes a wealth of information regarding admissions processes, student demographics, faculty and preceptor demographics, student expenses, and programmatic outcomes. This report is publicly available and should be referenced as a professional resource. Finally, attendance at conventions and seminars is highly encouraged because presentations on racial inclusivity are presented. Available resources can be found in Table 9.
Limitations and Future Directions
In this study, we asked participants to describe the institutional makeup of the university instead of the specific program diversity. Although participants often shared, broadly, the specific diversity and inclusion of their program, these data were not systematically collected. Many of the participants in this study and the research team identify as white. Therefore, there is a potential for the racial makeup of the participants in this study as well as the research team to implicitly bias the findings. We would like to acknowledge our own potential for bias and our white privilege as potential limitations in this study.
As individuals consider future directions in athletic training research, the profession must continue to develop and promote effective strategies for admissions, support the matriculation of racially minoritized students, and increase identifiable and equitable resources to better serve minoritized students. Further research should investigate specific recruitment and retention efforts aimed at minoritized students that program directors are actively implementing. This research is needed to determine the effectiveness of current strategies and areas of success and failures. Further research should also highlight the experience of racially minoritized students in professional master's athletic training degree programs. Gaining insight into the lived experiences of racially minoritized students may aid in the creation of future policies and programs. Finally, future research may focus on constructing a diverse research team.
Athletic trainers are an important piece of the health care system. Our clinician population should reflect both the population we are serving and the general population of the country. To increase the diversity of the athletic training profession, it is necessary to evaluate recruitment and retention efforts aimed at racially minoritized students. It is important to create robust policies, procedures, initiatives, and programs aimed at racially minoritized students as it pertains to graduate-level education. Participants in this study expressed the need for diverse marketing materials, integration of alumni and preceptors as marketers, and reliance on geographical location as important factors affecting recruitment efforts. Program directors also expressed the need for innovative and fresh ideas for recruitment. Those who expressed effective recruitment and retention efforts identified implementation of equitable resources aimed at racially minoritized students. These strategies included mentorship programs, scholarships, awareness of professional resources, diverse and inclusive marketing strategies, awareness and implementation of equitable admissions standards, and the need for individualized support. Overall, the profession should consider moving toward the creation of standardized protocol and procedure process for recruiting and retaining racially minoritized students.